“‘If a cold is treated energetically it will get well in seven days, while if left to itself it will get well in a week’. Put more cynically, ‘Nature cures, but the doctor takes the fee.’”- Testing Treatments
Colds are not the only conditions that recover on their own. Over 90% of low back pain cases don’t need any care from a physician or physical therapist.
Taking it a step further, many of the treatments provided in clinics lack research support. As a physical therapist, I see it across my profession daily. A physio in the UK, Adam Meakins, put it best:
Many therapists fill the gaping void of what they lack in communication, education and rehab skills with pink camo K-tape, laser guided acupuncture, electro-cupping and spinal manipulations!
While spinal manipulation — joint cracking — can provide some short-term relief, it does not “fix” anything and is not necessary to treat pain. The ultimate level of ridiculousness accrued a month ago when the Houston zoo applied kinesiotape — the colored tape you find on athletes — to an elephant.
First, kinesiotape is a placebo treatment — it only works if the person, or animal, believes it will. Second, the proposed mechanism — influencing nerve sensors in and just below our skin — doesn’t apply to an animal with skin that is 25 to 40 mm thick. Human skin registers at a robust 2mm.
Unnecessary treatments are not only prevalent in my field of physiotherapy. Opioids, spinal imaging, and injections are not first-line treatments. The research is clear on this. Yet, patients walk out receiving a combination of all three routinely after an initial bout of low back pain.
Why are ineffective and inappropriate treatments commonplace?
I’ll place a larger portion of the blame at the feet of providers, but patients need to take ownership too.
There are many reasons why providers seek ineffective treatments and why providers are all too happy to provide them.
A 2009 research article in a chiropractic journal provided three common and related themes:
1. The outcome bias
When we achieve a positive outcome, our mind cherry-picks the cause. I have done it as a clinician and a patient.
If you recently changed your diet, that will be the cause. Started focusing on sleep more? Of course that fixed your pain! Received an injection? Send a thank-you note to the doctor.
The natural history of the disease (common cold resolving in 7 days) is a boring and often ignored reason. Regression to the mean — we have good days and bad days — is often confused for one particular thing that helped or hurt our cause. The placebo effect causes real change signs and symptoms, but the mind caused the change, not the proposed mechanism of the treatment.
2. Confirmation Bias
Everyone is prone to cling to current beliefs and dismiss information that challenges those beliefs. Patients and clinicians are no expectation. If you believe a treatment worked, it will take more than one physical therapist on a laptop to convince you otherwise.
The Post Hoc, Ergo Propter Hoc fallacy — “after this, therefore because of this” — causes us to assume a cause and effect relationship. However, we cannot know cause and effects relationships in healthcare without controlled research.
If I treat a patient and their pain is better when they leave, many different elements could be the cause. They could have enjoyed being out of the house, reflected on a research promotion or new relationship, felt proud of the improvements in strength, started to believe they are going to fully recover or laughed throughout the session because of well-timed jokes from a hilarious physical therapist.
Or maybe it was natural history.
3. Valuing anecdotal experience over research
Our personal experiences grab our emotions. Personal evaluation of our experience is quick and convincing. Conversely, finding and reviewing high-quality research takes time and effort. Sometimes we seek a middle ground and ask the expert. Experts are not immune to bias or cognitive fallacies.
We have to hold each other accountable.
Start with Research but Don’t Forget Expectations
Any medical provider must start with high-quality research (randomized control trials to be specific) to determine if something has an effect. They can use systematic reviews and meta-analyses to gain a broad view of current research findings on a specific topic — such as the effectiveness of exercise for low back pain.
From there, providers use their experiences and the patient’s values to fine-tune treatment (timing, dosage, context, etc.) No matter how many times a treatment has “worked”, without controls conclusions cannot be drawn.
Understand placebo is a powerful force. The improvements are real but the results likely won’t last. Take time to determine why you are experiencing your results.
Keep in mind, our expectations influence our experience and the effectiveness of treatment. Seriously.
Here are the four categories of expectations and how they affect your healthcare experience:
Predicted Expectations: What the individual believes will occur.
Many studies have highlighted a link between expectation and clinical outcomes for individuals experiencing musculoskeletal pain. Predicted expectations, both positive and negative, have a direct relationship with musculoskeletal pain. These expectations will be heavily influenced by the information the patient receives — such as from their referring physician or social media — prior to starting physical therapy.
This applies to any situation. If you believe an interaction will be negative, such as a crucial conversation, then your awareness will have a negative frame. You will focus more on negative information and filter out the positive.
Ideal Expectations: An individual’s desire and hope.
Ideal expectations are what an individual wants to occur, while predicted are what an individual thinks will occur. Many patients will not share these as they believe they are not attainable and will lead to disappointment. The clinician must ask if they wish to learn and strive to achieve the ideal expectations. If they are attainable, and the clinician helps the patient achieve them, they will have an advocate for life.
Do you share or dare to strive for ideal expectations?
Normative Expectations: What an individual believes should occur.
While little is known of the impact normative expectations have on clinical outcomes, it does appear to play a role in patient satisfaction (or dissatisfaction if you fail to meet it). These are heavily influenced by the value proposition. If the commute time is long, the cost of care is high, or the clinician comes highly recommended, the patient will likely expect rapid, superior outcomes.
If you pay more, you expect a higher quality product or service.
Unformed Expectations: The expectations an individual is unaware of or is unwilling or unable to express.
This could be to a lack of previous experience or education necessary to form an expectation, or it could be the result of an activity being habitual and the patient hasn’t taken the time to develop an expectation.
Sometimes we need to reflect and spend time determining what our expectations are.
Expectations Influence Treatment Decisions
It is important to remember that expectations often change over time. What providers and patients expect to occur in the clinic or hospital influences what treatments are received. Even if the treatment is not supported in research — such as surgery for chronic pain — our bias and expectations often cause us to seek that treatment.
There are many conditions and ailments that benefit from a healthcare provider’s help, but treatment decisions should be made as a team, based on current evidence, clinician expertise, and patient values.
If all of these qualifications are not met, ineffective treatments may be used.
“The clinician’s expertise lies in diagnosing and identifying treatment options according to clinical priorities; the patient’s role is to identify and communicate their informed values and personal priorities, as shaped by their social circumstances.” — Testing Treatments
How Do You Protect Yourself?
There are a few strategies you can use:
- Get multiple opinions. It is common for people to get a second opinion for major medical decisions (e.g. surgery) but not for the mundane. The overuse of healthcare and the opioid crisis fall into the routine care category. Before adopting a treatment plan of any kind — whether it be medical, physical therapy, or chiropractic — make sure you have a full picture of available options.
- Do homework but use the right sources. If you read medical information online, make sure it has sources. Learn some research basics as many reporters and bloggers do not understand research and misinterpret it. It’s common for people to charry-pick information as well.
- Take time to make a decision. Snap decision making can be useful but it is highly biased and dependent on intuition — past experiences. Slow, critical thinking allows you to step back and decide if a treatment is the best option for you.
- Hold clinicians accountable. Ask them why they make a certain recommendation. What is the research support? What are the risks? What are the other options? If a clinician is unwilling to answer questions and adopts a position of authority or superiority, find someone else. Your health is too important.
Healthcare is a team sport. The only way to combat misinformation, disinformation, and ineffective treatments is for both clinicians and patients to hold the line.
It takes more work but is well worth the effort.